Speaker Request Form - Black Economic Alliance

Speaker Request

Event Name

In which capacity are you inviting Samantha Tweedy to speak?

Event Start Date

Event End Date

Date Samantha Tweedy Requested to Speak

Event Location (Street Address)

Event City/State

Event Type (i.e. Conference, Dinner, etc.)

Event Sponsor(s)

Type of Address

Suggested Speech Topic

Speech Start Time

Speech End Time

What is the primary message you want attendees to take away from Samantha Tweedy’s speech/remarks?

Panel Discussion –List other panelists and/or moderator

Keynote – List other event participants

Address Length

Audience Size

Audience Composition (e.g., healthcare industry, federal, state or local officials):

Dignitaries Present (Names and Titles):

Additional Attendance Requested Where Remarks are Not Required

Media Invited?

Yes

If Yes, please list Media invited

Media Reach

Is there an agenda available?

Yes

If yes, please upload Agenda

Drop files here or

Accepted file types: docx, doc, pdf, jpg, png, pptx, ppt, xlsx, xls, Max. file size: 10 MB.

Do you require a bio or photo?

Yes

Bio/Photo Deadline

The following will be compensated

Event Point of Contact (Name, Title, Organization, Business Address)

Contact Business Number

Contact Cell Phone Number

Contact Email Address(Required)

Additional Information

Upload Any Additional Supporting Items

Drop files here or

Accepted file types: docx, doc, pdf, jpg, png, pptx, ppt, xlsx, xls, Max. file size: 10 MB.